Post-Tonsillectomy Haemorrhage

Post-tonsillectomy bleeding is an uncommon, but potentially life threatening event. While the majority of post-tonsillectomy bleeds are self-limiting, a significant minority need to return to theatre urgently for control of the haemorrhage. ENT should be notified about ALL patients admitted with post-tonsillectomy bleeding. A small, self-limiting bleed may often be a prelude to a larger bleed (a 'heralding bleed') within the next 24 hours and thus all patients must be admitted for observation for 12 - 24 hours. The main difficulties arise from airway obstruction and hypovolaemic shock.

Types

Primary haemorrhage - occurs within the first 24 hours of procedure
Secondary haemorrhage - occurs after more than 24 hours from procedure (most commonly seen between days 5 and 10 post-op when the fibrin clot sloughs off, may be associated with infection)

Clinical features

Symptoms

Patients will present with either a history of bleeding or with active bleeding from the tonsillar fossa(e).
Parents of younger children may describe finding blood on the child's pillowcase or an episode of haemoptysis or haematemesis.
Excessive swallowing may also be an indicator of ongoing bleeding in young children. Have a high index of suspicion - the amount of bleeding is frequently underestimated in young children.

Signs

Examine the patient's throat for fresh bleeding. It is normal for the operative site to look yellow-white and sloughy after the operation.
Try to localise the source - left or right, inferior or superior pole. If the patient is not actively bleeding, look for an old bleeding point or a blood clot in the tonsillar fossae.
A full set of observations, including a BP should be obtained.

Important: Children may not report symptoms clearly - always examine thoroughly and have high suspicion for any reported blood or swallowing changes.

Management

Initial Resuscitation

Manage patient in Resus
Sit the patient up and encourage them to spit blood into a bowl
Suction should be available if needed
The patient should be kept 'Nil by mouth'
Central monitoring of heart rate, respiratory rate, pulse oximetry & blood pressure
Notify ENT Registrar/anaesthetist as required

Vascular Access & Bloods

Early IV access
- Aim to put in a large cannula if possible but any access is better than none
- Consider a second IV line
- Waiting for Ametop is acceptable if the patient is stable
Take bloods
- FBC
- Coagulation profile
- Group and Save/Cross match
- Venous Blood Gas

Medical Management

IV fluid resuscitation
IV analgesia
Consider IV antibiotics (e.g. benzylpenicillin and metronidazole)
Consider IV tranexamic acid
Consider blood transfusion
If not heavily bleeding, hydrogen peroxide gargles

Local Haemostasis

If severe bleeding and awaiting review/transfer, adrenaline soaked gauze pressed and held in the tonsillar fossa for as long as possible

Disposition

All patients with post-tonsillectomy bleeding must be admitted under ENT for observation (12-24 hours) regardless of bleeding severity at presentation.

Post-Tonsillectomy Bleed Summary

Key Points:

Red Flags:

Immediate Actions:

Treatment Options: